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DeltaCare® USA
Dental Health Care Program
for Eligible Employees
and Dependents
Combined Evidence of Coverage and
Disclosure Form
MIAMI-DADE COUNTY PUBLIC SCHOOLS
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Provided by:
Delta Dental Insurance Company
1130 Sanctuary Parkway
Alpharetta, GA 30009
Administered by:
Delta Dental Insurance Company
P.O. Box 1803
Alpharetta, GA 30023
800-693-2589
deltadentalins.com/mdcps
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EVIDENCE OF COVERAGE
DISCLOSURE FORM
DeltaCare® USA Dental Health Care Program
This booklet is a Combined Evidence of Coverage and Disclosure Form ("EOC") for your DeltaCare
USA Dental Health Care Program ("Program") provided by Delta Dental Insurance Company (“Delta
Dental”). The Program has been established and is administered in accordance with the provisions of
a Group Dental Service Contract ("Contract") issued by Delta Dental.
This EOC describes the provisions of the Contract between your group and Delta Dental. This EOC
provides coverage for dental services and Benefits as a Dental Plan Organization in accordance with
the terms and conditions specified in the Contract.
Since this information is being provided in electronic format, its accuracy should be verified before
receiving treatment. This information is not a guarantee of covered benefits, services or payments.
THE EOC CONSTITUTES ONLY A SUMMARY OF THE PROGRAM. THE CONTRACT MUST BE
CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF THE COVERAGE
PROVIDED UNDER IT.
A COPY OF THE CONTRACT WILL BE FURNISHED UPON REQUEST. ANY DIRECT CONFLICT
BETWEEN THE CONTRACT AND THE EOC WILL BE RESOLVED ACCORDING TO THE TERMS
WHICH ARE MOST FAVORABLE TO YOU. READ THIS EOC CAREFULLY AND COMPLETELY.
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW HOW TO OBTAIN
DENTAL BENEFITS.
The telephone number where you may obtain information about Benefits is 800-693-2589.
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Table of Contents
Definitions ..................................................................................................................................................... 1
Eligibility for Benefits ..................................................................................................................................... 2
Premiums ..................................................................................................................................................... 3
How to use the DeltaCare USA Program - Choice of Contract Dentist .......................................................... 3
Benefits, Limitations and Exclusions ............................................................................................................. 3
Copayments and Other Charges .................................................................................................................. 4
Emergency Services ..................................................................................................................................... 4
Specialist Services ........................................................................................................................................ 4
Claims for Reimbursement ........................................................................................................................... 4
Coordination of Benefits................................................................................................................................ 4
Enrollee Complaint Procedure ...................................................................................................................... 5
Renewal and Termination of Benefits ........................................................................................................... 6
Cancellation of Enrollment ............................................................................................................................ 6
Extension of Benefits .................................................................................................................................... 7
Conversion Privilege ..................................................................................................................................... 7
Optional Continuation of Coverage ............................................................................................................... 8
SCHEDULE A - Description of Benefits and Copayments........................................................................... 11
SCHEDULE B - Limitations and Exclusions of Benefits .............................................................................. 20
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Definitions
As used in this booklet:
Administrator means Delta Dental Insurance Company ("Delta Dental") or other entity designated by Delta
Dental, operating as an Administrator in the state of Florida. Administrative functions described in the
Contract and in this booklet may be performed by the Administrator, as designated by Delta Dental. The
mailing address for the Administrator is P.O. Box 1803, Alpharetta, GA 30023. The Administrator will
answer calls directed to 800-693-2589.
Benefits mean those dental services which are provided under the terms of the Group Dental Service
Contract and described in this booklet.
Client means the applicant (employer or other organization) contracting to obtain Benefits for Eligible
Employees.
Contract Dentist means a Dentist who provides services in general dentistry or pediatric dentistry and who
has agreed to provide Benefits to Enrollees under this Program.
Contract Orthodontist means a Dentist who specializes in orthodontics and who has agreed to provide
Benefits to Enrollees under this Program.
Contract Specialist means a Dentist who provides Specialist Services and has agreed to provide Benefits
to Enrollees under this Program.
Copayment means the amount charged to an Enrollee by a Contract Dentist for the Benefits provided
under this Program.
Dentist means a duly licensed Dentist legally entitled to practice dentistry at the time and in the state or
jurisdiction in which services are performed.
Eligible Dependent means any dependent of an Eligible Employee who is eligible for Benefits as described
in this booklet.
Eligible Employee means any employee or group member who is eligible for Benefits as described in this
booklet.
Emergency Services mean only those dental services immediately required for alleviation of severe pain,
swelling or bleeding, or immediately required to avoid placing the Enrollee's health in serious jeopardy.
Enrollee means an Eligible Employee ("Primary Enrollee") or an Eligible Dependent ("Dependent Enrollee")
enrolled to receive Benefits.
Open Enrollment Period means the period preceding the date of commencement of the contract term or
the 30-day period immediately preceding the annual anniversary of the contract term or a period as
otherwise requested by the Client and agreed to by Delta Dental.
Optional means any alternative procedure presented by the Contract Dentist that satisfies the same dental
need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of
the Contract.
Preauthorization means the process by which Delta Dental determines if a procedure or treatment is a
referable Benefit under the Enrollee's plan.
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Specialist Services mean services performed by a Dentist who specializes in the practice of oral surgery,
endodontics or periodontics, and which must be preauthorized by Delta Dental.
Spouse means a person related to or a partner of the Primary Enrollee:
1)
as defined and as may be required to be treated as a Spouse by the laws of the state where the
Contract is issued and delivered;
2)
as defined and as may be required to be treated as a Spouse by the laws of the state where the
Primary Enrollee resides; and
3)
as may be recognized by the Client.
We, Us or Our means Delta Dental or the Administrator as appropriate.
Eligibility for Benefits
Eligible Employees and Eligible Dependents receive Benefits as soon as they are enrolled in the Program.
Subject to cancellation as provided under this Program, enrollment of Eligible Employees and Eligible
Dependents is for a minimum period of one year.
You are eligible to enroll as an Eligible Employee if you meet the eligibility requirements defined by the
Client.
Eligible Dependents become eligible on:
1)
the date you are eligible for coverage;
2)
as soon as an Eligible Dependent becomes your dependent, or at any time subject to a change in
legal custody or lawful order to provide Benefits.
Eligible Dependents include Primary Enrollee’s Spouse and unmarried children as follows:
1)
from birth to the end of the calendar year in which they turn 25 if they are supported by the Primary
Enrollee, live in the Primary Enrollee’s household or are enrolled as full-time or part-time students in
an accredited school;
2)
grandchildren up to 18 months of age if the parent is a covered dependent; and
3)
from the beginning of the calendar year in which occurs their 26th birthday to the end of the calendar
year in which they turn 30 if they do not have children of their own, they are Florida residents or fulltime or part-time students and not provided coverage as a named subscriber, insured, enrollee or
covered person under any other group, blanket or franchise health insurance policy or individual
health benefits plan or is not entitled to benefits under Title XVIII of the Social Security Act.
Children include natural children, stepchildren, foster children, adopted children, children placed for
adoption and children of a partner as recognized by the Client. Children/students must be dependent upon
the Primary Enrollee for support and maintenance. The dependents of Primary Enrollees are eligible to
enroll on the same date that the employee, of whom they are a dependent, becomes a Primary Enrollee.
Later-acquired dependents become eligible as soon as they acquire dependent status.
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An overage unmarried dependent child may be eligible if:
1)
he/she is incapable of self-sustaining employment because of a physically or mentally disabling
injury, illness or condition that began prior to reaching the limiting age;
2)
he/she is chiefly dependent on the Eligible Employee for support; and
3)
proof of dependent's disability is provided within 31 days of request. Such requests will not be made
more than once a year following a two year period after this dependent reaches the limiting age.
Enrollment will continue as long as the dependent relies on the Eligible Employee for support
because of a physically or mentally disabling injury, illness or condition that began before he/she
reached the limiting age.
Dependents on active military duty are not eligible.
Premiums
This Program requires premiums to be paid to us. If you are required to pay all or any portion of the
premiums, you will be advised of the amount prior to enrollment and it will be deducted from your earnings
by payroll deduction, or you will be requested to pay it directly. The Client will be responsible for sending all
payments of premiums to us except payments you are requested to pay directly.
How to use the DeltaCare USA Program - Choice of Contract Dentist
To enroll in this Program, you must select a Contract Dentist for both yourself and any Dependent Enrollee
from the list of Contract Dentists furnished during the enrollment process. You and your Eligible Dependents
may select no more than one Contract Dentist per family member. If you fail to select a Contract Dentist or
the Contract Dentist selected becomes unavailable, we will request the selection of another Contract Dentist
or assign you to a Contract Dentist. You may change your assigned Contract Dentist by directing a request
to the Customer Service department at 800-693-2589. In order to ensure that your Contract Dentist is
notified and our eligibility lists are correct, changes in Contract Dentists must be requested prior to the 21st
of the month for changes to be effective the first day of the following month.
Shortly after enrollment you will receive a DeltaCare USA membership packet that tells you the effective
date of your Program and the address and telephone number of your Contract Dentist. After the effective
date in your membership packet, you may obtain dental services which are Benefits. To make an
appointment, simply call your Contract Dentist's facility and identify yourself as a DeltaCare USA Enrollee.
Initial appointments should be scheduled within four weeks unless a specific time has been requested.
Inquiries regarding availability of appointments and accessibility of Dentists should be directed to the
Customer Service department at 800-693-2589.
EACH ENROLLEE MUST GO TO HIS OR HER ASSIGNED CONTRACT DENTIST TO OBTAIN
COVERED SERVICES, EXCEPT FOR SERVICES PROVIDED BY A SPECIALIST PREAUTHORIZED BY
DELTA DENTAL, OR FOR EMERGENCY SERVICES REQUIRED WHILE 35 MILES OR MORE FROM
THE CONTRACT DENTIST'S FACILITY. ANY OTHER TREATMENT IS NOT COVERED UNDER THIS
PROGRAM.
If your assigned Contract Dentist's agreement with Delta Dental terminates, that Contract Dentist will
complete (a) a partial or full denture for which final impressions have been taken, and (b) all work on every
tooth upon which work has started (such as completion of root canals in progress and delivery of crowns
when teeth have been prepared).
Benefits, Limitations and Exclusions
This Program provides the Benefits described in the Description of Benefits and Copayments subject to the
limitations and exclusions. The services are performed as deemed appropriate by your attending Contract
Dentist. A Contract Dentist may provide services either personally or through associated Dentists,
technicians or hygienists who may lawfully perform the services.
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Copayments and Other Charges
You are required to pay any Copayments listed in the Description of Benefits and Copayments directly to
the Dentist who provides treatment. Charges for broken appointments (unless notice is received by the
Dentist at least 24 hours in advance or an emergency prevented such notice), and charges for visits after
normal visiting hours are listed in the Description of Benefits and Copayments.
Emergency Services
You should contact your assigned Contract Dentist for Emergency Services whenever possible. If you are
unable to reach your Contract Dentist for Emergency Services, you should call the Customer Service
department at 800-693-2589 for assistance in obtaining urgent care. During non-business hours or if you
are 35 miles or more from your assigned Contract Dentist, you do not need a referral and may seek
treatment from a Dentist other than your assigned Contract Dentist.
Benefits for emergency treatment received from any Dentist, other than the assigned Contract Dentist, are
limited to a maximum of $100.00 per emergency, per Enrollee. You are responsible for the Copayment(s)
as well as any charges over the $100.00 benefit maximum.
Emergency dental care is limited to palliative treatment for the elimination of dental pain. Further treatment
must be obtained from the assigned Contract Dentist.
Specialist Services
Specialist Services must be referred by the assigned Contract Dentist and must be preauthorized by Delta
Dental. All preauthorized Specialist Services will be paid by us less any applicable Copayments.
If the services of a Contract Orthodontist are needed, please refer to Orthodontics in the Description of
Benefits and Copayments, and the limitations and exclusions to determine which procedures are covered
under this Program.
Claims for Reimbursement
Claims for covered Emergency Services or preauthorized Specialist Services must be submitted to us within
90 days of the end of treatment. Valid claims received after the 90 day period will be reviewed if you can
show that it was not reasonably possible to submit the claim within that time. Except in the absence of legal
capacity of the claimant, all claims must be received within one year of the treatment date. The address for
claims submission is: Claims Department, P.O. Box 1810, Alpharetta, GA 30023.
In the event we fail to pay a Contract Dentist or Contract Specialist, you will not be liable to that Dentist for
any sums owed by us. By statute, the DeltaCare USA provider contract contains a provision prohibiting a
Contract Dentist or Contract Specialist from charging an Enrollee for any sums owed by Delta Dental.
Except for the provisions in Emergency Services, if you have not received Preauthorization for treatment
from an out-of-network Dentist, and we fail to pay that out-of-network Dentist, you may be liable to that
Dentist for the cost of services.
Coordination of Benefits
This Program provides Benefits without regard to coverage by any other group insurance policy or any other
group health benefits program if the other policy or program covers services or expenses in addition to
dental care. Otherwise, Benefits provided under this Program by specialists or out-of-network Dentists are
coordinated with such other group dental insurance policy or any group dental benefits program. The
determination of which policy or program is primary shall be governed by the rules stated in the Contract.
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When this plan is secondary, it may reduce its Benefits so that the total Benefits paid or provided by all
plans during a claim determination period are not more than 100 percent of total Allowable Expenses.
"Allowable Expense" is defined as a service or expense, including deductibles and Copayments, that is
covered at least in part by any of the plans covering the person.
An Enrollee shall provide to Delta Dental, and Delta Dental may release to or obtain from any insurance
company or other organization, any information about the Enrollee that is needed to administer coordination
of benefits. Delta Dental shall, in its sole discretion, determine whether any reimbursement to an insurance
company or other organization is warranted under these coordination of benefits provisions, and any such
reimbursement paid shall be deemed to be Benefits under this Contract. Delta Dental shall have the right to
recover from a Dentist, Enrollee, insurance company or other organization, as Delta Dental chooses, the
amount of any Benefits paid by Delta Dental which exceeds its obligations under these coordination of
benefit provisions.
Enrollee Complaint Procedure
Informal Grievances
An Enrollee who has a grievance against Delta Dental for any matter arising out of this Contract may make
an informal complaint by calling the toll-free number 800-693-2589. A grievance is not considered formal
until Delta Dental receives a written complaint.
Formal Grievances
Written complaints may be addressed to:
Quality Management Department
P.O. Box 1860
Alpharetta, Georgia 30023
Written communication must include 1) the name of the patient, 2) the name, address, telephone number
and identification number of the Primary Enrollee, 3) the name of the Client and 4) the Dentist's name and
facility location.
For complaints involving an adverse benefit determination (e.g. a denial, modification or termination of a
requested benefit or claim) the Enrollee must file a request for review (a complaint) with Delta Dental within
one year after receipt of the adverse determination. Our review will take into account all information,
regardless of whether such information was submitted or considered initially. The review shall be conducted
by a person who is neither the individual who made the original benefit determination, nor the subordinate of
such individual. Upon request and free of charge, we will provide you with copies of any pertinent
documents that are relevant to the benefit determination, a copy of any internal rule, guideline, protocol,
and/or explanation of the scientific or clinical judgment if relied upon in making the benefit determination. If
the review of a denial is based in whole or in part on a lack of medical necessity, experimental treatment, or
a clinical judgment in applying the terms of the Contract, Delta Dental shall consult with a Dentist who has
appropriate training and experience. If any consulting Dentist is involved in the review, the identity of such
consulting Dentist will be available upon request.
Within 10 business days of the receipt of any complaint, including adverse benefit determinations as
described above, the quality management coordinator will forward to you an acknowledgement of receipt of
the complaint. Certain requests may require that you be referred to a Dentist in your area for clinical
evaluation of the dental services provided. We will make a determination, in writing, within 30 days of
receipt of a complaint or shall provide a written explanation if additional time is required to report on the
complaint. In no event will the decision on the request for review be sent more than 90 days after Delta
Dental receives it.
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Appeal of Decision
A review of the decision shall be undertaken if a written request for an appeal of the determination is made
within 30 days of the date of the written determination. We shall undertake a full and fair review upon any
request. We may require additional documents as we deem necessary in making such a review. We shall
provide a written response to you within 30 days after receipt of the appeal and supporting documentation
or a written explanation if additional time is required to issue the results.
An Enrollee who is dissatisfied with the decision may appeal in writing to the State of Florida Office of
Insurance Regulation.
The State of Florida Office of Insurance Regulation may be contacted at any time, concerning any complaint
or request for assistance, by writing to 200 East Gaines St., Tallahassee, FL 32399, or by calling the
Office's toll-free consumer hotline: 800-342-2762.
Renewal and Termination of Benefits
This Program renews on the anniversary of the contract term unless we provide notice of a change in
premiums or Benefits and the Client does not accept the change. All Benefits terminate for any Enrollee as
of the date that this Program is terminated, such person ceases to be eligible under the terms of this
Program, or such person's enrollment is canceled under the terms of this Program. We are not obligated to
continue to provide Benefits to any such person in such event, except for completion of single procedures
commenced while this Program was in effect.
Cancellation of Enrollment
Subject to the Enrollee Complaint Procedure, the Optional Continuation of Coverage provision or the
Extension of Benefits or Conversion Privilege below, an Eligible Employee's or Eligible Dependent's
enrollment under this Program may be canceled, or renewal of enrollment refused, in the following events:
1)
2)
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Immediately:
a)
upon loss of eligibility as described in this Certificate of Coverage; or
b)
if the premiums are not paid by or on behalf of the Enrollee on the date due, or within the 30day premium grace period. The Enrollee may continue to receive Benefits during the 30-day
grace period and may be reinstated during the term of the Contract upon payment of any
unpaid premium. If coverage is not reinstated, the Enrollee will be responsible for the cost of
services received during the 30-day grace period; or
c)
if the Contract is terminated or not renewed.
Upon 45 days written notice if:
a)
the Enrollee's behavior is disruptive, unruly, abusive, unlawful, fraudulent, or uncooperative
to the extent that the Enrollee's continuing participation seriously impairs the organization's
ability to provide services to other Enrollees;
b)
the Enrollee commits fraud or misrepresentation in applying for or presenting any claim for
Benefits under this Contract;
c)
the Enrollee misuses the documents provided as evidence of Benefits available under the
Contract; or
d)
the Enrollee furnishes incorrect or incomplete information to Delta Dental in order to
fraudulently obtain services.
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Prior to cancellation, Delta Dental will make every effort to resolve problems through the grievance
procedures and will determine that the Enrollee's behavior is not due to the use of the services or mental
illness.
Cancellation of a Primary Enrollee's enrollment shall automatically cancel the enrollment of any of his or her
Dependent Enrollees.
Extension of Benefits
Benefits will continue to be provided for dental services provided to a patient who is totally disabled when
coverage ends, if:
1)
The Dentist recommends the services to the patient in writing, and the services began, while
coverage was in effect.
2)
The services are not for routine examinations, prophylaxis, x-rays, sealants, or orthodontic services.
3)
The services are provided within 90 days after the patient's coverage ended, and the coverage did
not end because the patient (or, in the case of a dependent child, the child's parent) voluntarily
terminated coverage.
The extension of Benefits ends at the earlier of:
1)
the end of the 90-day period in 3) above; or
2)
the day the patient becomes covered under another contract which does not exclude benefits for the
procedure because of an elimination period or limitations.
All limitations and exclusions in the Contract will continue to apply during the extension.
Conversion Privilege
A person who has been continuously covered under the Contract for at least three months, and who loses
that coverage, may convert to individual coverage within 31 days after losing the coverage without providing
evidence of insurability. The person must pay premium at individual rates.
However, a person may not convert to individual coverage if the lost coverage is replaced by similar
coverage within 31 days, or if the person lost coverage because he or she:
1)
did not pay any required premium or contribution;
2)
committed fraud or material misrepresentation in applying for coverage;
3)
willfully and knowingly misused the Contract identification or member certificate;
4)
willfully and knowingly gave incorrect or incomplete information to fraudulently obtain coverage;
5)
left the geographic service area and does not intend to live there in the future; or
6)
acted in a way that was so disruptive, unruly, abusive, or uncooperative that continuing the coverage
would prevent Delta Dental from providing proper services to that person or to any other patients.
However, before Delta Dental cancels an Enrollee's coverage it will try to resolve the problem through the
grievance procedure and will make sure that the person's behavior is not caused by the services provided
or mental illness.
Cancellation of a Primary Enrollee's enrollment shall automatically cancel the enrollment of any of his or her
Dependent Enrollees.
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Optional Continuation of Coverage
The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain employers
having 20 or more employees) requires that continued health care coverage be made available to "Qualified
Beneficiaries" who lose health care coverage under the group plan as a result of a "Qualifying Event." You
may be entitled to continue coverage under this plan, at your expense, if certain conditions are met. The
period of continued coverage depends on the Qualifying Event.
DEFINITIONS
The meaning of key terms used in this section is shown below.
Qualified Beneficiary means:
1)
you and/or your dependents who are enrolled in the Delta Dental plan on the day before the
Qualifying Event, or
2)
a child who is born to or placed for adoption with you during the period of continued coverage,
provided such child is enrolled within 30 days of birth or placement for adoption.
Qualifying Event means any of the following events which, except for the election of this continued
coverage, would result in a loss of coverage under the dental plan:
Event 1.
the termination of employment (other than termination for gross misconduct) or the reduction
in work hours, by your employer;
Event 2.
your death;
Event 3.
your divorce or legal separation from your spouse;
Event 4.
your dependent's loss of dependent status under the plan; and
Event 5.
as to your dependents only, your entitlement to Medicare.
You or your means the Primary Enrollee.
PERIODS OF CONTINUED COVERAGE
Qualified Beneficiaries may continue coverage for 18 months following the month in which Qualifying Event
1 occurs.
This 18-month period can be extended for a total of 29 months, provided:
1)
a determination is made under Title II or Title XVI of the Social Security Act that an individual is
disabled on the date of the Qualifying Event or becomes disabled at any time during the first 60 days
of continued coverage; and
2)
notice of the determination is given to the employer during the initial 18 months of continued
coverage and within 60 days of the date of the determination.
This period of coverage will end on the first day of the month that begins more than 30 days after the date of
the final determination that the disabled individual is no longer disabled. You must notify your employer or
Delta Dental within 30 days of any such determination.
If, during the 18 months continuation period resulting from Qualifying Event 1, your dependents, who are
Qualified Beneficiaries, experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for
up to a total of 36 months (inclusive of the period continued under Qualifying Event 1).
Your dependents, who are Qualified Beneficiaries, may continue coverage for 36 months following the
occurrence of Qualifying Events 2, 3, 4 or 5.
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When an employer has filed for bankruptcy under Title 11, United States Code, benefits may be
substantially reduced or eliminated for retired employees and their dependents, or the surviving spouse of a
deceased retired employee. If this benefit reduction or elimination occurs within one year before or one year
after filing, it is considered a Qualifying Event. If the Primary Enrollee is a retiree, and has lost coverage
because of this Qualifying Event, he or she may choose to continue coverage until his or her death. The
Primary Enrollee's dependents who have lost coverage because of this Qualifying Event may choose to
continue coverage for up to 36 months following the Primary Enrollee's death.
ELECTION OF CONTINUED COVERAGE
Your employer shall notify Delta Dental within 30 days of Qualifying Event 1. A Qualified Beneficiary must
notify his or her employer in writing within 60 days of Qualifying Events 2, 3, 4 or 5, or within 60 days of
receiving the election notice from the employer. Otherwise, the option of continued coverage will be lost.
Within 14 days of receiving notice of a Qualifying Event, the employer will provide a Qualified Beneficiary
with the necessary benefits information, monthly premium charge, enrollment forms, and instructions to
allow election of continued coverage.
A Qualified Beneficiary will then have 60 days to give his or her employer written notice of the election to
continue coverage. Failure to provide this written notice of election to the employer within 60 days will result
in loss of the right to continue coverage.
A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the initial
premium to his or her employer, which includes the premium for each month since the loss of coverage.
Failure to pay the required premium within the 45 days will result in loss of the right to continue coverage
and any premium received after that will be returned to the Qualified Beneficiary.
CONTINUED COVERAGE BENEFITS
The Benefits under the continued coverage will be the same as those provided to active employees and
their dependents who are still enrolled in the dental plan. If the employer changes the coverage for active
employees, the continued coverage will change as well. Premiums will be adjusted to reflect the changes
made.
TERMINATION OF CONTINUED COVERAGE
A Qualified Beneficiary's coverage will terminate at the end of the month in which any of the following
events first occur:
1)
the allowable number of consecutive months of continued coverage is reached;
2)
failure to pay the required premiums in a timely manner;
3)
the employer ceases to provide any group dental plan to its employees;
4)
the individual moves out of the plan's service area;
5)
the individual first obtains coverage for dental Benefits, after the date of the election of continued
coverage, under another group health plan (as an employee or dependent) which does not contain
or apply any exclusion or limitation with respect to any pre-existing condition of such a person, if that
pre-existing condition is covered under this plan; or
6)
entitlement to Medicare.
The employer shall notify Delta Dental within 30 days of the occurrence of any of the above events. Once
continued coverage ends, it cannot be reinstated.
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TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT
If the dental contract between the employer and Delta Dental terminates prior to the time that the
continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary either 30
days prior to the termination or when all Enrollees are notified, whichever is later, of the ability to elect
continuation of coverage under the employer's subsequent dental plan, if any. The continuation coverage
will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered
under the Delta Dental plan had such plan with the former employer not terminated. The employer shall
notify the successor plan in writing of the Qualified Beneficiaries receiving continuation coverage so they
may be notified of how to continue coverage. The continuation coverage will terminate if a Qualified
Beneficiary fails to comply with the requirements pertaining to enrollment in and payment of premiums to
the new group benefit plan.
OPEN ENROLLMENT CHANGE OF COVERAGE
A Qualified Beneficiary may elect to change continuation coverage during any subsequent open enrollment
period, if the employer has contracted with another plan to provide coverage to its active employees. The
continuation coverage under the other plan will be provided only for the balance of the period that a
Qualified Beneficiary would have remained under the Delta Dental plan.
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SCHEDULE A
Description of Benefits and Copayments
The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the
limitations and exclusions of the Program. Please refer to Schedule B for further clarification of Benefits. Enrollees should
discuss all treatment options with their Contract Dentist prior to services being rendered.
Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA
program and is not to be interpreted as CDT-2015 procedure codes, descriptors or nomenclature that are under copyright
by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions.
Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance
with federal legislation.
All non-listed services are available with your selected Contract Dentist or Contract Specialist at 75% of their filed fees.
Code
Description
Enrollee Pays
D0100-D0999 I. DIAGNOSTIC
D0120
Periodic oral evaluation - established patient .................................................................................................. $0.00
D0140
Limited oral evaluation - problem focused ....................................................................................................... $0.00
D0145
Oral evaluation for a patient under three years of age and counseling with primary caregiver ...................... $0.00
D0150
Comprehensive oral evaluation - new or established patient .......................................................................... $0.00
D0160
Detailed and extensive oral evaluation - problem focused, by report .............................................................. $0.00
D0170
Re-evaluation - limited, problem focused (established patient; not post-operative visit) ................................ $0.00
D0171
Re-evaluation – post-operative office visit ....................................................................................................... $0.00
D0180
Comprehensive periodontal evaluation - new or established patient ............................................................ $20.00
D0190
Screening of a patient ..................................................................................................................................... $0.00
D0191
Assessment of a patient................................................................................................................................... $0.00
D0210
intraoral - complete series of radiographic images - limited to 1 series every 24 months ............................... $0.00
D0220
Intraoral - periapical first radiographic image .................................................................................................. $0.00
D0230
Intraoral - periapical, each additional radiographic image ............................................................................... $0.00
D0240
Intraoral - occlusal radiographic image ............................................................................................................ $0.00
D0250
Extraoral - first radiographic image .................................................................................................................. $0.00
D0260
Extraoral - each additional radiographic image ............................................................................................... $0.00
D0270
Bitewing radiograph - single radiographic image ............................................................................................. $0.00
D0272
Bitewings radiographs - two radiographic images ........................................................................................... $0.00
D0273
Bitewings - radiographs - three radiographic images ...................................................................................... $0.00
D0274
Bitewings radiographs - four radiographic images - limited to 1 series every 6 months ................................. $0.00
D0277
Vertical bitewings - 7 to 8 radiographic images ............................................................................................... $0.00
D0330
Panoramic radiographic image ....................................................................................................................... $0.00
D0350
2D oral/facial photographic images obtained intraorally or extraorally ............................................................ $0.00
D0351
3D photographic image .................................................................................................................................... $0.00
D0415
Collection of microorganisms for culture and sensitivity .................................................................................. $0.00
D0425
Caries susceptibility tests ................................................................................................................................ $0.00
D0431
Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including
premalignant and malignant lesions, not to include cytology or biopsy procedures ..................................... $50.00
D0460
Pulp vitality tests .............................................................................................................................................. $0.00
D0470
Diagnostic casts ............................................................................................................................................... $0.00
D0472
Accession of tissue, gross examination, preparation and transmission of written report. ............................... $0.00
D0473
Accession of tissue, gross and microscopic examination, preparation and transmission of
written report. ................................................................................................................................................... $0.00
D0474
Accession of tissue, gross and microscopic examination, including assessment of surgical
margins for presence of disease, preparation and transmission of written report. .......................................... $0.00
D0486
Accession of transepithelial cytologic sample, microscopic examination, preparation and
transmission of written report ........................................................................................................................... $0.00
D0601
Caries risk assessment and documentation, with a finding of low risk
- limited to children age 3 to 19, 1 every 3 years ............................................................................................ $0.00
D0602
Caries risk assessment and documentation, with a finding of moderate risk
- limited to children age 3 to 19, 1 every 3 years ............................................................................................ $0.00
S-A-FL-MDCPS-R15
11
FLD62
V15
D0603
D0999
Caries risk assessment and documentation, with a finding of high risk
- limited to children age 3 to 19, 1 every 3 years ............................................................................................ $0.00
Unspecified diagnostic procedure, by report - includes office visit, per visit including all fees for sterilization
and/or infection control (in addition to other services). .................................................................................... $5.00
D1000-D1999
II. PREVENTIVE
D1110
Prophylaxis cleaning - adult - 2 per year ......................................................................................................... $0.00
D1110
Additional prophylaxis cleaning - adult; 2 within year .................................................................................... $35.00
D1120
Prophylaxis cleaning - child - 2 per year .......................................................................................................... $0.00
D1120
Additional prophylaxis cleaning - child; 2 within year .................................................................................... $35.00
D1206
Topical application of fluoride varnish - 2 per year; 2 D1206 or D1208 per year ............................................ $0.00
D1208
Topical application of fluoride - excluding varnish - 2 per year; 2 D1206 or D1208 per year ......................... $0.00
D1310
Nutritional counseling for control of dental disease. ........................................................................................ $0.00
D1320
Tobacco counseling for the control and prevention of oral disease ................................................................ $0.00
D1330
Oral hygiene instructions ................................................................................................................................. $0.00
D1351
Sealant - per tooth - limited to permanent molars through age 15 .................................................................. $0.00
D1352
Preventive resin restoration in a moderate to high carries risk patient - permanent tooth .............................. $0.00
D1353
Sealant repair – per tooth - limited to permanent molars through age 15 ....................................................... $0.00
D1510
Space maintainer - fixed - unilateral .............................................................................................................. $65.00
D1515
Space maintainer - fixed - bilateral ................................................................................................................ $65.00
D1520
Space maintainer - removable - unilateral ................................................................................................... $105.00
D1525
Space maintainer - removable - bilateral ..................................................................................................... $105.00
D1550
Re-cement or re-bond space maintainer ....................................................................................................... $15.00
D1555
Removal of fixed space maintainer ................................................................................................................ $15.00
D2000-D2999
III. RESTORATIVE
- Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.
- An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium
metal. There is no copayment per crown unit in additional to regular copayments for porcelain on molars.
- When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $125.00
per crown, beyond the 6th unit.
- Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old.
D2140
Amalgam - one surface, primary or permanent ............................................................................................. $20.00
D2150
Amalgam - two surfaces, primary or permanent ............................................................................................ $25.00
D2160
Amalgam - three surfaces, primary or permanent ......................................................................................... $30.00
D2161
Amalgam - four or more surfaces, primary or permanent ............................................................................. $35.00
D2330
Resin-based composite - one surface, anterior ............................................................................................ $35.00
D2331
Resin-based composite - two surfaces, anterior .......................................................................................... $40.00
D2332
Resin-based composite - three surfaces, anterior ........................................................................................ $50.00
D2335
Resin-based composite - four or more surfaces or involving incisal angle (anterior) ................................... $55.00
D2390
Resin-based composite crown, anterior ....................................................................................................... $65.00
D2391
Resin-based composite - one surface, posterior .......................................................................................... $75.00
D2392
Resin-based composite - two surfaces, posterior .......................................................................................... $85.00
D2393
Resin-based composite - three surfaces, posterior ...................................................................................... $95.00
D2394
Resin-based composite - four or more surfaces, posterior ......................................................................... $120.00
D2510
Inlay - metallic - one surface ....................................................................................................................... $155.00
D2520
Inlay - metallic - two surfaces ..................................................................................................................... $165.00
D2530
Inlay - metallic - three or more surfaces ..................................................................................................... $190.00
D2542
Onlay - metallic - two surfaces .................................................................................................................... $370.00
D2543
Onlay - metallic - three surfaces ................................................................................................................. $370.00
D2544
Onlay - metallic - four or more surfaces ...................................................................................................... $370.00
D2610
Inlay - porcelain/ceramic - one surface ........................................................................................................ $370.00
D2620
Inlay - porcelain/ceramic - two surfaces ...................................................................................................... $370.00
D2630
Inlay - porcelain/ceramic - three or more surfaces ...................................................................................... $370.00
D2642
Onlay - porcelain/ceramic - two surfaces..................................................................................................... $370.00
D2643
Onlay - porcelain/ceramic - three surfaces .................................................................................................. $370.00
D2644
Onlay - porcelain/ceramic - four or more surfaces ...................................................................................... $370.00
D2650
Inlay - resin-based composite - one surface ............................................................................................... $370.00
D2651
Inlay - resin-based composite - two surfaces ............................................................................................. $370.00
D2652
Inlay - resin-based composite - three or more surfaces ............................................................................. $370.00
D2662
Onlay - resin-based composite - two surfaces ........................................................................................... $370.00
S-A-FL-MDCPS-R15
12
FLD62
V15
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
D2799
D2910
D2915
D2920
D2921
D2929
D2930
D2931
D2932
D2933
D2940
D2941
D2949
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2970
D2971
D2980
D2981
D2982
D2983
D2990
Onlay - resin-based composite - three surfaces ......................................................................................... $370.00
Onlay - resin-based composite - four or more surfaces ............................................................................. $370.00
Crown - resin (indirect) ................................................................................................................................ $370.00
Crown - ¾ resin-based composite (indirect) ................................................................................................ $370.00
Crown - resin with high noble metal ............................................................................................................ $370.00
Crown - resin with predominantly base metal ............................................................................................. $370.00
Crown - resin with noble metal ................................................................................................................... $370.00
Crown - porcelain/ceramic substrate ........................................................................................................... $370.00
Crown - porcelain fused to high noble metal ............................................................................................... $370.00
Crown - porcelain fused to predominantly base metal ............................................................................... $370.00
Crown - porcelain fused to noble metal ...................................................................................................... $370.00
Crown - ¾ cast high noble metal ................................................................................................................ $370.00
Crown - ¾ cast predominantly base metal ................................................................................................. $370.00
Crown - ¾ cast noble metal ........................................................................................................................ $370.00
Crown - ¾ porcelain/ceramic ....................................................................................................................... $370.00
Crown - full cast high noble metal ............................................................................................................... $370.00
Crown - full cast predominantly base metal ................................................................................................ $370.00
Crown - full cast noble metal ...................................................................................................................... $370.00
Crown - titanium ........................................................................................................................................... $370.00
Provisional crown ............................................................................................................................................. $0.00
Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration .................................................. $15.00
Re-cement or re-bond indirectly fabricated or prefabricated post and core .................................................... $0.00
Re-cement or re-bond crown ......................................................................................................................... $15.00
Reattachment of tooth fragment, incisal edge or cusp (anterior) ................................................................. $55.00
Prefabricated porcelain/ceramic crown – (anterior) primary tooth ................................................................. $45.00
Prefabricated stainless steel crown - primary tooth ....................................................................................... $25.00
Prefabricated stainless steel crown - permanent tooth .................................................................................. $25.00
Prefabricated resin crown - anterior primary tooth ........................................................................................ $45.00
Prefabricated stainless steel crown with resin window - anterior primary tooth ............................................ $45.00
Protective restoration ....................................................................................................................................... $0.00
Interim therapeutic restoration – primary dentition .......................................................................................... $0.00
Restorative foundation for an indirect restoration .......................................................................................... $60.00
Core buildup, including any pins when required ............................................................................................ $60.00
Pin retention - per tooth, in addition to restoration ......................................................................................... $10.00
Cast post and core in addition to crown, indirectly fabricated - includes canal preparation .......................... $60.00
Each additional indirectly fabricated post - same tooth - includes canal preparation .................................... $60.00
Prefabricated post and core in addition to crown - base metal post; includes canal preparation ................. $30.00
Post removal ................................................................................................................................................. $10.00
Each additional prefabricated post - same tooth - base metal post; includes canal preparation .................. $30.00
Labial veneer (resin laminate) - chairside .................................................................................................... $250.00
Labial veneer (resin laminate) – laboratory ................................................................................................. $300.00
Labial Veneer (Porcelain Laminate)--Lab .................................................................................................... $350.00
Temporary crown (fractured tooth) - palliative treatment only ........................................................................ $0.00
Additional procedures to construct new crown under existing partial denture framework ............................ $50.00
Crown repair necessitated by restorative material failure................................................................................ $0.00
Inlay repair necessitated by restorative material failure .................................................................................. $0.00
Onlay repair necessitated by restorative material failure................................................................................. $0.00
Veneer repair necessitated by restorative material failure .............................................................................. $0.00
Resin infiltration of incipient smooth surface lesions ....................................................................................... $0.00
D3000-D3999 IV. ENDODONTICS
D3110
Pulp cap - direct (excluding final restoration) .................................................................................................. $5.00
D3120
Pulp cap - indirect (excluding final restoration) ................................................................................................ $5.00
D3220
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the
dentinocemental junction and application of medicament ............................................................................. $40.00
D3221
Pulpal debridement, primary and permanent teeth ....................................................................................... $60.00
D3222
Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development ......................... $40.00
D3230
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) ............................... $40.00
D3240
Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) ............................. $40.00
D3310
Root canal - endodontic therapy, anterior tooth (excluding final restoration) .............................................. $200.00
D3320
Root canal - endodontic therapy, bicuspid tooth (excluding final restoration) ............................................. $210.00
S-A-FL-MDCPS-R15
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FLD62
V15
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3427
D3430
D3450
D3910
D3920
D3950
Root canal - endodontic therapy, molar (excluding final restoration) .......................................................... $310.00
Treatment of root canal obstruction; non-surgical access ............................................................................. $85.00
Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth .............................................. $110.00
Internal root repair of perforation defects....................................................................................................... $85.00
Retreatment of previous root canal therapy - anterior ................................................................................ $230.00
Retreatment of previous root canal therapy - bicuspid ............................................................................... $280.00
Retreatment of previous root canal therapy - molar ................................................................................... $325.00
Apexification/recalcification – initial visit (apical closure / calcific repair of perforations,
root resorption, etc.) ....................................................................................................................................... $70.00
Apexification/recalcification - interim medication replacement ...................................................................... $70.00
Apexification/recalcification - final visit (includes completed root canal therapy - apical
closure/calcific repair of perforations, root resorption, etc.) ........................................................................... $70.00
Apicoectomy - anterior ................................................................................................................................ $190.00
Apicoectomy - bicuspid (first root) ................................................................................................................ $95.00
Apicoectomy - molar (first root) ..................................................................................................................... $95.00
Apicoectomy (each additional root) .............................................................................................................. $80.00
Periradicular surgery without apicoectomy .................................................................................................. $190.00
Retrograde filling - per root ........................................................................................................................... $60.00
Root amputation, per root ........................................................................................................................... $110.00
Surgical procedure for isolation of tooth with rubber dam ............................................................................. $19.00
Hemisection (including any root removal), not including root canal therapy ................................................. $90.00
Canal preparation and fitting of preformed dowel or post.............................................................................. $15.00
D4000-D4999
V. PERIODONTICS
- Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
- Periodontal maintenance copay includes periodontal charting for planning treatment of periodontal disease and
periodontal hygiene instruction.
D4210
Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per
quadrant ....................................................................................................................................................... $180.00
D4211
Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per
quadrant ......................................................................................................................................................... $55.00
D4212
Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth ..................................... $55.00
D4240
Gingival flap procedure, including root planing - four or more contiguous teeth or tooth
bounded spaces per quadrant ..................................................................................................................... $170.00
D4241
Gingival flap procedure, including root planing - one to three contiguous teeth or tooth
bounded spaces per quadrant ..................................................................................................................... $130.00
D4245
Apically positioned flap ................................................................................................................................ $165.00
D4249
Clinical crown lengthening - hard tissue ...................................................................................................... $160.00
D4260
Osseous surgery (including elevation of a full thickness flap and closure) – four or
more contiguous teeth or tooth bounded spaces per quadrant ................................................................... $330.00
D4261
Osseous surgery (including elevation of a full thickness flap and closure) – one to three
contiguous teeth or tooth bounded spaces per quadrant ............................................................................ $248.00
D4263
Bone replacement graft - first site in quadrant ............................................................................................. $180.00
D4264
Bone replacement graft - each additional site in quadrant ............................................................................ $95.00
D4265
Biologic materials to aid in soft and osseous tissue regeneration ................................................................. $95.00
D4266
Guided tissue regeneration - resorbable barrier, per site ............................................................................ $215.00
D4267
Guided tissue regeneration – nonresorbable barrier, per site (includes membrane removal) .................... $255.00
D4270
Pedicle soft tissue graft procedure .............................................................................................................. $250.00
D4273
Subepithelial connective tissue graft procedures, per tooth .......................................................................... $75.00
D4274
Distal or proximal wedge procedure (when not performed in conjunction with surgical
procedures in the same anatomical area) ................................................................................................... $100.00
D4275
Soft tissue allograft ...................................................................................................................................... $380.00
D4277
Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous
tooth position in graft.................................................................................................................................... $260.00
D4278
Free soft tissue graft procedure (including donor site surgery), each additional contiguous
tooth or edentulous tooth position in same graft site ................................................................................... $260.00
D4320
Provisional splinting – intracoronal ................................................................................................................ $95.00
D4321
Provisional splinting – extracoronal ............................................................................................................... $85.00
D4341
Periodontal scaling and root planing, four or more teeth per quadrant - limited to 4 quadrants
during any 12 consecutive months ................................................................................................................ $60.00
S-A-FL-MDCPS-R15
14
FLD62
V15
D4342
D4355
D4381
D4910
D4910
D4921
Periodontal scaling and root planing, one to three teeth, per quadrant - limited to 4 quadrants
during any 12 consecutive months ................................................................................................................ $45.00
Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1
treatment in any 12 consecutive months ....................................................................................................... $50.00
Localized delivery of antimicrobial agents via controlled release vehicle into diseased
crevicular tissue, per tooth ............................................................................................................................. $60.00
Periodontal maintenance - limited to 2 treatments per year .......................................................................... $50.00
Additional periodontal maintenance - beyond 2 per year .............................................................................. $60.00
Gingival irrigation – per quadrant ..................................................................................................................... $0.00
D5000-D5899
VI. PROSTHODONTICS (removable)
- For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if
needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be
provided at the Contract Dentist's facility where the denture was originally delivered.
- Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months.
- Replacement of a denture or a partial denture requires the existing denture to be 5+ years old.
D5110
Complete denture - maxillary ..................................................................................................................... $375.00
D5120
Complete denture - mandibular .................................................................................................................. $375.00
D5130
Immediate denture - maxillary .................................................................................................................... $375.00
D5140
Immediate denture - mandibular ................................................................................................................. $375.00
D5211
Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) ....................... $375.00
D5212
Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) ................... $375.00
D5213
Maxillary partial denture - cast metal framework with resin denture base (including any
conventional clasps, rests and teeth) ......................................................................................................... $375.00
D5214
Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps,
rests and teeth) ........................................................................................................................................... $375.00
D5225
Maxillary partial denture - flexible base (including any clasps, rests and teeth).......................................... $480.00
D5226
Mandibular partial denture - flexible base (including any clasps, rests and teeth) ...................................... $480.00
D5281
Removable unilateral partial denture – one piece cast metal (including clasps and teeth)......................... $360.00
D5410
Adjust complete denture - maxillary .............................................................................................................. $20.00
D5411
Adjust complete denture - mandibular .......................................................................................................... $20.00
D5421
Adjust partial denture - maxillary .................................................................................................................. $20.00
D5422
Adjust partial denture - mandibular ............................................................................................................... $20.00
D5510
Repair broken complete denture base........................................................................................................... $30.00
D5520
Replace missing or broken teeth - complete denture (each tooth) ................................................................ $30.00
D5610
Repair resin denture base ............................................................................................................................. $30.00
D5620
Repair cast framework ................................................................................................................................... $50.00
D5630
Repair or replace broken clasp ...................................................................................................................... $30.00
D5640
Replace broken teeth - per tooth ................................................................................................................... $30.00
D5650
Add tooth to existing partial denture .............................................................................................................. $45.00
D5660
Add clasp to existing partial denture .............................................................................................................. $70.00
D5670
Replace all teeth and acrylic on cast metal framework (maxillary) .............................................................. $165.00
D5671
Replace all teeth and acrylic on cast metal framework (mandibular) .......................................................... $165.00
D5710
Rebase complete maxillary denture ........................................................................................................... $125.00
D5711
Rebase complete mandibular denture ........................................................................................................ $125.00
D5720
Rebase maxillary partial denture ................................................................................................................ $125.00
D5721
Rebase mandibular partial denture ............................................................................................................. $125.00
D5730
Reline complete maxillary denture (chairside) .............................................................................................. $65.00
D5731
Reline complete mandibular denture (chairside) .......................................................................................... $65.00
D5740
Reline maxillary partial denture (chairside) .................................................................................................. $65.00
D5741
Reline mandibular partial denture (chairside) .............................................................................................. $65.00
D5750
Reline complete maxillary denture (laboratory) ............................................................................................ $50.00
D5751
Reline complete mandibular denture (laboratory) ........................................................................................ $50.00
D5760
Reline maxillary partial denture (laboratory) ................................................................................................. $50.00
D5761
Reline mandibular partial denture (laboratory) ............................................................................................. $50.00
D5810
Interim complete denture (maxillary) .......................................................................................................... $230.00
D5811
Interim complete denture (mandibular) ........................................................................................................ $230.00
D5820
Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months .......................................... $160.00
D5821
Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months ...................................... $170.00
D5850
Tissue conditioning, maxillary ....................................................................................................................... $40.00
S-A-FL-MDCPS-R15
15
FLD62
V15
D5851
D5862
Tissue conditioning, mandibular ................................................................................................................... $40.00
Precision attachment, by report ................................................................................................................... $160.00
D5900-D5999
VII. MAXILLOFACIAL PROSTHETICS - Not Covered
D6000-D6199
VIII. IMPLANT SERVICES - Not Covered
D6200-D6999
IX. PROSTHODONTICS, FIXED (each retainer and each pontic constitutes a unit in a fixed partial
denture (bridge)
- An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium
metal. There is no copayment per crown/bridge unit in additional to regular copayments for porcelain on molars.
- When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional
$125.00 per unit, beyond the 6th unit.
- Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old.
D6210
Pontic - cast high noble metal ..................................................................................................................... $370.00
D6211
Pontic - cast predominantly base metal ...................................................................................................... $370.00
D6212
Pontic - cast noble metal ............................................................................................................................ $370.00
D6214
Pontic - titanium ........................................................................................................................................... $370.00
D6240
Pontic - porcelain fused to high noble metal ................................................................................................ $370.00
D6241
Pontic - porcelain fused to predominantly base metal ................................................................................. $370.00
D6242
Pontic - porcelain fused to noble metal ....................................................................................................... $370.00
D6245
Pontic - porcelain/ceramic ........................................................................................................................... $370.00
D6250
Pontic - resin with high noble metal ............................................................................................................ $370.00
D6251
Pontic - resin with predominantly base metal ............................................................................................. $370.00
D6252
Pontic - resin with noble metal .................................................................................................................... $370.00
D6253
Provisional pontic ............................................................................................................................................. $0.00
D6545
Retainer – cast metal for resin bonded fixed prosthesis .............................................................................. $370.00
D6549
Resin retainer - for resin bonded fixed prosthesis ....................................................................................... $370.00
D6600
Inlay - porcelain/ceramic, two surfaces ....................................................................................................... $370.00
D6601
Inlay - porcelain/ceramic, three or more surfaces ...................................................................................... $370.00
D6602
Inlay - cast high noble metal, two surfaces ................................................................................................. $370.00
D6603
Inlay - cast high noble metal, three or more surfaces ................................................................................. $370.00
D6604
Inlay - cast predominantly base metal, two surfaces .................................................................................. $370.00
D6605
Inlay - cast predominantly base metal, three or more surfaces .................................................................. $370.00
D6606
Inlay - cast noble metal, two surfaces ......................................................................................................... $370.00
D6607
Inlay - cast noble metal, three or more surfaces ........................................................................................ $370.00
D6608
Onlay - porcelain/ceramic, two surfaces ..................................................................................................... $370.00
D6609
Onlay - porcelain/ceramic, three or more surfaces ..................................................................................... $370.00
D6610
Onlay - cast high noble metal, two surfaces ............................................................................................... $370.00
D6611
Onlay - cast high noble metal, three or more surfaces ............................................................................... $370.00
D6612
Onlay - cast predominantly base metal, two surfaces ................................................................................ $370.00
D6613
Onlay - cast predominantly base metal, three or more surfaces ................................................................ $370.00
D6614
Onlay - cast noble metal, two surfaces ....................................................................................................... $370.00
D6615
Onlay - cast noble metal, three or more surfaces ....................................................................................... $370.00
D6710
Crown – indirect resin based composite ...................................................................................................... $370.00
D6720
Crown - resin with high noble metal ............................................................................................................ $370.00
D6721
Crown - resin with predominantly base metal ............................................................................................. $370.00
D6722
Crown - resin with noble metal ................................................................................................................... $370.00
D6740
Crown - porcelain/ceramic ........................................................................................................................... $370.00
D6750
Crown - porcelain fused to high noble metal ............................................................................................... $370.00
D6751
Crown - porcelain fused to predominantly base metal ................................................................................ $370.00
D6752
Crown - porcelain fused to noble metal ...................................................................................................... $370.00
D6780
Crown - ¾ cast high noble metal ................................................................................................................ $370.00
D6781
Crown - ¾ cast predominantly base metal ................................................................................................. $370.00
D6782
Crown - ¾ cast noble metal ........................................................................................................................ $370.00
D6783
Crown - ¾ porcelain/ceramic ....................................................................................................................... $370.00
D6790
Crown - full cast high noble metal ............................................................................................................... $370.00
D6791
Crown - full cast predominantly base metal ................................................................................................ $370.00
D6792
Crown - full cast noble metal ..................................................................................................................... $370.00
D6794
Crown - titanium ........................................................................................................................................... $370.00
D6930
Re-cement or re-bond fixed partial denture ................................................................................................... $15.00
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D6940
D6950
D6980
Stress breaker ............................................................................................................................................. $110.00
Precision attachment ................................................................................................................................... $195.00
Fixed partial denture repair necessitated by restorative material failure ....................................................... $45.00
D7000-D7999
X. ORAL AND MAXILLOFACIAL SURGERY
- Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
D7111
Extraction, coronal remnants - deciduous tooth ............................................................................................ $20.00
D7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal).............................................. $20.00
D7210
surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth,
and including elevation of mucoperiosteal flap if indicated............................................................................ $50.00
D7220
Removal of impacted tooth - soft tissue......................................................................................................... $75.00
D7230
Removal of impacted tooth - partially bony.................................................................................................... $85.00
D7240
Removal of impacted tooth - completely bony ............................................................................................. $135.00
D7241
Removal of impacted tooth - completely bony, with unusual surgical complications .................................. $150.00
D7250
Surgical removal of residual tooth roots (cutting procedure) ......................................................................... $65.00
D7251
Coronectomy – intentional partial tooth removal ......................................................................................... $150.00
D7270
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth .................................... $80.00
D7280
Surgical access of an unerupted tooth ........................................................................................................ $100.00
D7282
Mobilization of erupted or malpositioned tooth to aid eruption ...................................................................... $90.00
D7283
Placement of device to facilitate eruption of impacted tooth ......................................................................... $90.00
D7285
Incisional biopsy of oral tissue-hard (bone, tooth) - does not include pathology laboratory
procedures ................................................................................................................................................... $150.00
D7286
Incisional biopsy of oral tissue-soft - does not include pathology laboratory procedures ............................. $60.00
D7287
Exfoliative cytological sample collection ........................................................................................................ $50.00
D7288
Brush biopsy - transepithelial sample collection ............................................................................................ $50.00
D7310
Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per
quadrant ......................................................................................................................................................... $45.00
D7311
Alveolplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant ................... $25.00
D7320
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per
quadrant ....................................................................................................................................................... $100.00
D7321
Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant ......................................................................................................................................................... $65.00
D7471
Removal of lateral exostosis - (maxilla or mandible) ..................................................................................... $80.00
D7472
Removal of torus palatinus ............................................................................................................................ $60.00
D7473
Removal of torus mandibularis ...................................................................................................................... $60.00
D7485
Surgical reduction of osseous tuberosity ....................................................................................................... $60.00
D7510
Incision and drainage of abscess - intraoral soft tissue ................................................................................. $35.00
D7511
Incision and drainage of abscess - intraoral soft tissue - complicated .......................................................... $35.00
D7520
Incision and drainage of abscess – extraoral soft tissue ............................................................................... $35.00
D7521
Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of
multiple fascial spaces) .................................................................................................................................. $35.00
D7910
Suture of Recent Small Wounds up to 5cm ................................................................................................... $25.00
D7960
Frenulectomy – also known as frenectomy or frenotomy – separate procedure not incidental to another
procedure ....................................................................................................................................................... $90.00
D7963
Frenuloplasty ................................................................................................................................................. $90.00
D7970
Excision hyperplastic tissue - per arch .......................................................................................................... $55.00
D7971
Excision of pericoronal gingiva ...................................................................................................................... $40.00
D8000-D8999
XI. ORTHODONTICS
- The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24
months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed $25.00, may apply.
- The Retention Copayment includes adjustments and/or office visits up to 24 months. Pre and post orthodontic records
include:
Pre and post orthodontic records include:
The benefit for pre-treatment records and diagnostic services includes: ........................................................ $0.00
D0210
Intraoral - complete series (including bitewings)
D0322
Tomographic survey
D0330
Panoramic radiographic image
D0340
Cephalometric radiographic image
D0350
2D oral/facial photographic images obtained intraorally or extraorally
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D0351
D0470
3D photographic image
Diagnostic casts
D0210
D0470
The benefit for post-treatment re cords includes: ............................................................................................ $0.00
Intraoral - complete series (including bitewings)
Diagnostic casts
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D8660
D8670
D8680
D8693
D8694
D8999
Limited orthodontic treatment of the primary dentition ............................................................................. $1,095.00
Limited orthodontic treatment of the transitional dentition - child or adolescent to age 19 ...................... $1,095.00
Limited orthodontic treatment of the adolescent dentition - adolescent to age 19 ................................... $1,095.00
Limited orthodontic treatment of the adult dentition - adults, including covered dependent
adult children ............................................................................................................................................. $1,095.00
Interceptive orthodontic treatment of the primary dentition ................................................................ 25% Discount
Interceptive orthodontic treatment of the transitional dentition .......................................................... 25% Discount
Comprehensive orthodontic treatment of the transitional dentition - child or adolescent
to age 19 .................................................................................................................................................. $2,095.00
Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19 .................... $2,095.00
Comprehensive orthodontic treatment of the adult dentition - adults, including covered
dependent adult children ......................................................................................................................... $2,095.00
Removable appliance therapy ............................................................................................................ 25% Discount
Fixed appliance therapy ...................................................................................................................... 25% Discount
Pre-orthodontic treatment examination to monitor growth and development ................................................ $35.00
Periodic orthodontic treatment visit.................................................................................................................. $0.00
Orthodontic retention (removal of appliances, construction and placement of removable
retainers) ..................................................................................................................................................... $300.00
Re-bond or re-cement fixed retainer ................................................................................................................ $0.00
Repair of fixed retainers, includes reattachment - limited to 2 per 6 month period ......................................... $0.00
Unspecified orthodontic procedure, by report - includes treatment planning session ................................. $250.00
D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES
D9110
Palliative (emergency) treatment of dental pain - minor procedure ............................................................... $15.00
D9120
Fixed partial denture sectioning ....................................................................................................................... $0.00
D9210
Local anesthesia not in conjunction with operative or surgical procedures..................................................... $0.00
D9211
Regional block anesthesia ............................................................................................................................... $0.00
D9212
Trigeminal division block anesthesia ............................................................................................................... $0.00
D9215
Local anesthesia in conjunction with operative or surgical procedures ........................................................... $0.00
D9219
Evaluation for deep sedation or general anesthesia ....................................................................................... $0.00
D9220
Deep sedation/general anesthesia - first 30 minutes .................................................................................. $150.00
D9221
Deep sedation/general anesthesia - each additional 15 minutes .................................................................. $45.00
D9230
Inhalation of nitrous oxide/anxiolysis, analgesia ............................................................................................ $15.00
D9241
Intravenous moderate (conscious) sedation/analgesia – first 30 minutes ................................................... $150.00
D9242
Intravenous moderate (conscious) sedation/analgesia – each additional 15 minutes .................................. $45.00
D9248
Non-intravenous moderate (conscious) sedation .......................................................................................... $15.00
D9310
Consultation - diagnostic service provided by dentist or physician other than requesting
dentist or physician .......................................................................................................................................... $5.00
D9430
Office visit for observation (during regularly scheduled hours) - no other services performed ....................... $0.00
D9440
Office visit - after regularly scheduled hours ................................................................................................. $30.00
D9450
Case presentation, detailed and extensive treatment planning ....................................................................... $0.00
D9610
Therapeutic parenteral drug, single administration ....................................................................................... $15.00
D9612
Therapeutic parenteral drugs, two or more administrations, different medications ....................................... $25.00
D9630
Other drugs and/or medicaments, by report .................................................................................................. $15.00
D9910
Application of desensitizing medicament ....................................................................................................... $15.00
D9931
Cleaning and inspection of a removable appliance ......................................................................................... $0.00
D9940
Occlusal guard, by report - limited to 1 in 3 years ......................................................................................... $85.00
D9942
Repair and/or reline of occlusal guard ........................................................................................................... $40.00
D9951
Occlusal adjustment, limited .......................................................................................................................... $25.00
D9952
Occlusal adjustment, complete .................................................................................................................... $100.00
D9975
External bleaching for home application, per arch; includes materials and fabrication of
custom trays ................................................................................................................................................. $125.00
D9986
Missed appointment - without 24 hour notice ................................................................................................ $25.00
D9987
Canceled appointment - without 24 hour notice ............................................................................................ $25.00
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If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified
Copayment. During the course of treatment, your Contract Dentist may recommend the services of a dental specialist.
Your Contract Dentist may refer you directly to a Contract Specialist; referral approval from Delta Dental is not required.
However, certain procedures may require pre-treatment authorization prior to care. The Enrollee pays the Copayment
specified for such services.
Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed fees." "Filed fees"
mean the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the
Customer Service department at 800-693-2589.
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SCHEDULE B
Limitations of Benefits
1.
The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of
Benefits and Copayments.
2.
Any procedures not specifically listed as a covered benefit in this Plan’s Schedule A are available at 75% of the
filed fees of the Enrollee’s selected Contract Dentist or Contract Specialist, provided the services are included in
the treatment plan and are not specifically excluded.
3.
Dental procedures or services performed solely for cosmetic purposes or solely for appearance are available at
75% of the filed fees of the Enrollee’s selected Contract Dentist or Contract Specialist, unless specifically listed as
a covered benefit on Schedule A.
4.
If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six
crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $25.00 above the listed
Copayment for each of these services after the sixth unit has been provided.
5.
General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and
in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures
D7230, D7240, and D7241).
6.
The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists, however it is
available at 75% of the Enrollee’s selected Contract Dentist or Contract Specialist’s filed fees.
7.
Benefits provided by a pediatric Dentist are limited to children, through the end of the month that the dependent
child turns age eight.
8.
The cost to an Enrollee receiving orthodontic treatment whose coverage is canceled or terminated for any reason
will be based on the Contract Orthodontist's filed fee for the treatment plan. The Contract Orthodontist will prorate
the amount for the number of months remaining to complete treatment. The Enrollee makes payment directly to
the Contract Orthodontist as arranged.
9.
Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original
effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they
continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun.
Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta
Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.
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Exclusions of Benefits
1.
Any procedure that has poor prognosis for a successful result and reasonable longevity based on the condition of
the tooth or teeth and/or surrounding structures, or is inconsistent with generally accepted standards for dentistry.
2.
Services solely for cosmetic purposes, with the exception of procedure D9975 (External bleaching for home
application, per arch), or for conditions that are a result of hereditary or developmental defects, such as cleft
palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking
enamel, except for the treatment of newborn children with congenital defects or birth abnormalities.
3
Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) for
children under 16 years of age.
4.
Lost, stolen or broken appliances including, but not limited to, full or partial dentures, space maintainers, crowns,
fixed partial dentures (bridges) and orthodontic appliances.
5.
Procedures, appliances or restoration if the purpose is to change vertical dimension, replace or stabilize tooth
structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings or to diagnose or treat
abnormal conditions of the temporomandibular joint (TMJ) with the exception of procedures D9951 and D9952 as
shown on Schedule A.
6.
Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain
denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and
appliances associated therewith) and personalization and characterization of complete and partial dentures.
7.
Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other
services associated with a dental implant.
8.
Consultations or other diagnostic services for non-covered benefits.
9.
Dental services received from any dental facility other than the assigned Contract Dentist or an authorized dental
specialist (oral surgeon, endodontist, periodontist or Contract Orthodontist) except for Emergency Services as
described in the Contract and/or Evidence of Coverage.
10.
All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other
similar care facility.
11.
Over-the-counter drugs; prescription drugs not administered by the Enrollee’s selected Contract Dentist or
Contract Specialist.
12.
Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the
DeltaCare USA Program. Examples include: teeth prepared for crowns, root canals in progress, full or partial
dentures for which an impression has been taken and orthodontics unless qualified for the orthodontic treatment in
progress provision.
13.
Changes in orthodontic treatment necessitated by accident of any kind.
14.
Myofunctional and parafunctional appliances and/or therapies.
15.
Composite or ceramic brackets, lingual adaptation of orthodontic bands, Invisalign and other specialized or
cosmetic alternatives to standard fixed and removable orthodontic appliances.
16.
Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.
17.
Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or
other public program other than Medicaid or Medicare.
18.
Dental services required while serving in the Armed Forces or any country or international authority.
19.
Dental services considered experimental in nature.
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20.
Orthognathic surgery.
21.
Any dental services, or appliances, which are determined to be not reasonable and/or necessary for maintaining or
improving the Enrollee’s dental health, as determined by the DeltaCare USA Contract Dentist.
22.
Treatment of malignancies, cysts, or neoplasms unless specifically listed as a covered benefit on this Plan’s
Schedule of Benefits. Any services related to pathology laboratory fees.
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